Embassy of Wyoming Valley

Inspectors wroteBased on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to notify a resident's responsible party of a significant change in condition, specifically a fall with a head injury, and the resulting physician-ordered treatment, for one of 14 sampled residents (Resident 1).

Inspectors wroteBased on a review of clinical records, select facility policy, Treatment Administration Records and staff interviews, it was determined that the facility failed to provide nursing services in accordance with professional standards of practice by failing to ensure licensed nursing staff administered a physician-ordered wound treatment as prescribed for one of 14 residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to maintain an accurate and complete clinical record for one of 14 sampled residents (Resident 1).

Inspectors wroteBased on observations, it was determined the facility did not provide a clean, comfortable, and homelike environment for residents on three of three floors observed.

Inspectors wroteBased on a review of facility policy, prior survey findings, the facility's Plan of Correction (POC), and observations made during the revisit survey, it was determined the facility failed to implement and sustain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, monitored, and corrected ongoing deficient practice related to environmental cleanliness and maintenance.

Inspectors wroteBased on observation, resident and staff interviews, and review of facility dietary schedules, menus, and dietary records, it was determined the facility failed to consistently maintain sufficient dietary staff to effectively carry out the functions of the food and nutrition services department. This failure resulted in meals not being consistently served at palatable temperatures, the planned menu not being followed, and the food and nutrition services department not being maintained in a sanitary manner.

Inspectors wroteBased on observation, review of select facility policy, and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of foodborne illness in the food and nutrition services department and failed to ensure that food storage in personal refrigerators was adequately monitored and maintained within safe temperatures to prevent foodborne illness for one resident with a personal refrigerator (Resident 5).

Inspectors wroteBased on observation, review of documentation provided by the facility, select policies, and staff interview, it was determined that the facility failed to develop and implement a water management program, identify potential factors related to the prevalence of urinary tract infections, and implement interventions based on these factors to decrease the occurrence and further failed to ensure compliance with facility policy to reduce the spread of infection was consistently implemented, including observations made on one out of two nursing units (Second Floor Nursing Unit).

Inspectors wroteBased on observations, review of clinical records, facility policy, and staff interviews, it was determined the facility failed to ensure residents' call lights were accessible to reasonably accommodate a resident's need for assistance for three out of 23 residents sampled (Residents 3, 29, 7, and 63).

Inspectors wroteBased on observations and resident and staff interviews, it was determined the facility failed to provide a clean, comfortable, and homelike environment for residents, including concerns expressed by six out of six residents during a resident group interview (Residents 46, 56, 71, 77, 83, and 94) and four out of 23 sampled residents (Residents 9, 14, 20, and 52).

Inspectors wroteBased on observation, a review of select facility policy, and resident and staff interviews, it was determined that the facility failed to ensure the required information and resources were made available to residents for filing grievances with the facility and for filing grievances with independent entities, including six out of six residents interviewed during a resident group meeting (Residents 46, 56, 71, 77, 83, and 94).

Inspectors wroteBased on a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents, including experiences expressed by 1 out of the 23 sampled residents (Resident 50) and as expressed by residents during a resident group interview (Residents 46, 56, 71, 77, 83, and 94)

Inspectors wroteBased on observations, review of facility documentation, review of personnel records, and interviews with staff, it was determined the facility failed to ensure the activities program was directed by a qualified professional for one of one activities personnel files reviewed (Employee 1).

Inspectors wroteBased on observations, staff interviews, review of manufacturer storage guidelines, and review of facility policy, it was determined that the facility failed to ensure drugs and biologicals were properly stored and that expired or improperly labeled medications were removed from use. Specifically, the facility failed to maintain required refrigeration temperatures for injectable medications used to manage blood sugar levels and failed to discard expired or improperly labeled medications, affecting 11 residents medications in two of two medication rooms observed. (Residents 5, 9, 10, 25, 42, 66, 72, 78, 85, 92, and 94).

Inspectors wroteBased on observations, review of select facility policies, test tray evaluation, review of facility-provided documentation, and resident and staff interviews, it was determined the facility failed to ensure foods were served at safe and palatable temperatures for four of 23 residents sampled (Residents 12, 26, 30, and 1).

Inspectors wroteBased on a review of clinical records, facility-provided documentation, and employee interviews, it was determined the facility failed to ensure the accuracy and completeness of resident medical records for one of 3 closed records (Resident 98).

Inspectors wroteBased on a review of facility policy, prior survey findings, the facility's Plan of Correction (POC), and observations made during the revisit survey, it was determined the facility failed to implement and sustain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, monitored, and corrected ongoing deficient practice related to environmental cleanliness and maintenance.

Inspectors wroteBased on a review of clinical records, facility-provided documentation, and interviews with staff and the resident representative, it was determined the facility failed to ensure that the resident representative was fully informed, in advance and in sufficient detail, by the physician or other practitioner, of the resident's condition, the risks and benefits of proposed treatment, and available treatment alternatives, in order to make an informed decision regarding care. This failure occurred for one of three closed records reviewed (Resident 98).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure physician orders accurately reflected a the resident's documented resuscitation status for one of 23 residents reviewed (Resident 73).

Inspectors wroteBased on a review of clinical records and a staff interview, it was determined the facility failed to timely complete a significant change Minimum Data Set assessment for one of 23 residents reviewed (Resident 8).

Inspectors wroteBased on clinical record review, observation, select policy review, and staff interview, it was determined the facility failed to maintain an environment free from accident hazards for one of 23 sampled residents (Resident 5).

Inspectors wroteBased on a review of clinical records, facility policies, and staff interviews, it was determined the facility failed to develop and implement individualized, person-centered interventions to manage dementia-related behavioral symptoms in order to promote resident safety and to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident out of 23 residents sampled (Resident 7).

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined the facility failed to ensure the provision of adaptive dining equipment as prescribed to support safe eating for one of 23 sampled residents. (Resident 16)

Inspectors wroteBased on clinical record review, review of the facility admission agreement and arbitration documents, and staff interviews, it was determined the facility failed to ensure arbitration agreements were implemented to ensure that an arbitration agreement allowed for the mutual selection of a neutral arbitrator for one resident out of three discharged residents reviewed. (Resident 98).

Inspectors wroteBased on review of the facility's abuse policy, clinical records, investigation reports, and interviews with residents and staff, it was determined that the facility failed to assure that one resident (Resident 1) out of six sampled residents was free from sexual abuse perpetrated by another resident (Resident 2).

Inspectors wroteBased on a review of clinical records, select facility policy, investigative documentation provided by the facility, and interviews with facility staff, it was determined the facility failed to protect one of five sampled residents (Resident 3) from neglect by not implementing the individualized care plan intervention of a mechanical lift for all transfers, resulting in actual harm in the form of a spiral fracture of the left tibia. This deficiency is cited as past noncompliance

Inspectors wroteBased on staff interview and a review of employee qualifications it was determined that the facility failed to employ a full-time qualified director of food and nutrition services manager in the absence of a full-time qualified dietitian.

Inspectors wroteBased on observation and resident and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in resident areas on two of two resident floors (second floor and third floor residential units, and third floor shower room).

Inspectors wroteBased on observation, review of clinical records and select facility policy, and staff interview, it was determined the facility failed to ensure the evaluation of a resident's need and use of physical restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom, and failed to obtain informed consent prior to the use of the physical restraint for one of one sampled resident with restraints (Resident 1).

Inspectors wroteBased on observation, a review of clinical records, and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to follow a physician order to discontinue a treatment for one of 21 sampled residents (Resident 57).

Inspectors wroteBased on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to provide person-centered care by not ensuring compliance with physician orders for the management of a Peripherally Inserted Central Catheter (PICC) line, failed to maintain the availability of prescribed emergency supplies, and failed to meet the resident's clinical needs for one of 21 sampled residents (Resident 31).

Inspectors wroteBased on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to implement enhanced barrier infection control procedures for one out of 21 residents sampled (Resident 38), properly store clean towels designated for resident use in one out of two shower rooms on the Third Floor Nursing Unit, and maintain infection control practices related to reduce the potential for infections for one (Resident 36) out of two sampled residents with an indwelling urinary Foley catheter (flexible tube which is placed in the bladder to drain urine).

Inspectors wroteBased on review of clinical records and staff interview, it was determined the facility failed to provide person-centered care for one resident out of one resident receiving hemodialysis. (Resident 87).

Inspectors wroteBased on observation, review of select facility policy, and staff interviews, it was determined that the facility failed to implement a process for providing pharmacy services, including access to emergency medications when not available onsite, and failed to maintain oversight of the facility's medication dispensing system.

Inspectors wroteBased on review of select facility policy, observation, and staff interview it was determined the facility failed to ensure that drugs were stored at an acceptable temperature on two of two nursing units.

Inspectors wroteBased on a review of the facility's automated emergency medication system, applicable state regulations, facility policies, and staff interviews, it was determined that the facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring pharmacy services necessary for daily pharmacy operations according to state requirements of Pa. Code title 49.

Inspectors wroteBased on clinical record review, facility-initiated transfer notices and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for one resident out of the 21 residents sampled. (Resident 60).

Inspectors wroteBased on a review of clinical records and staff interview it was determined the facility failed to provide residents or their representatives with written information of the facility's bed hold policy upon transfer to the hospital of one resident out of 21 residents sampled (Residents 39).

Inspectors wroteBased on observations, a review of the facility's planned cycle menus, and resident and staff interview it was determined that the facility failed follow written planned menus for four of seven residents sampled. (Resident 14, 55, 87, and 56).

Inspectors wroteBased on observation, review of food committee minutes, resident and staff interviews, and test tray results, it was determined the facility failed to serve meals that were palatable and at a safe and appetizing temperature for four of the 7 residents sampled (Residents 1, 56, 14, and 87)

Inspectors wroteBased on review of clinical records, the facility's abuse prohibition policy, select investigative reports, and interviews with staff and residents, it was determined the facility failed to ensure that a resident was free from neglect by not providing care with assistance of two-persons as planned to ensure safety and prevent major injuries, fractures to the left distal femur and right distal tibial, for one resident, Resident 2, out of eight sampled residents for abuse prohibition.

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to timely follow-up with required dental services for one Medicaid payor source resident out of two residents sampled (Resident 49).

Inspectors wroteBased on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness, in the dietary department and the second- floor resident food storage area.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment on two of two resident care units. (Second and Third Floor)

Inspectors wroteBased on review of select facility policy and clinical records, and interviews with staff, it was determined the facility failed to provide nursing services consistent with professional standards of practice to ensure that licensed nurses properly evaluated and provided nursing care for a change in condition for one resident out of 20 sampled (Resident 52) and failed to follow physician orders for bowel protocol for two residents out of 20 sampled (Resident 40 and 15).

Inspectors wroteBased on review of facility planned menus and select facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure residents were provided meals that accommodated food preferences for four of 20 residents reviewed (Residents 59, 66, 32, and 40). Findings Include: A review of a facility policy entitled Alternative Menu Program that was last reviewed by the facility on January 18, 2024, indicated that always available items must be posted by the menu on all floors for the residents to see and all items must be available for the meal. There are three menu items on the alternate menu that includes grilled cheese, hamburger on a bun, and a deli sandwich. Based on resident decisions from the facility's monthly Food Committee meeting, two selections per the resident's selection will be added to the permanent always available menu items. [...]

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards on one of two resident care units. (Second Floor)

Inspectors wroteBased on review of select facility policies/reports and clinical records, and staff, and resident interviews it was determined that the facility failed to provide necessary behavioral health care to promote the highest practicable physical and psychosocial well-being of one resident out of 20 sampled (Resident 52).

Inspectors wroteBased on review of manufacturer's directions for use, observation, and staff interview, it was determined that the facility failed to ensure adherence to pharmacy supplies expiration/use by dates on one of three resident units (Second Floor).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to timely obtain radiology/diagnostic services to meet the needs of one resident of 20 sampled (Resident 52).